Referring Office Form
(Please Fill Out Form When Visiting Offices)
Team Member
Dr. Dudziack
Dr. Choi
Dr. Kim
Dr. Paxman
Dr. Hanna
Jennifer Jauregui
Kelsey VanVoorhis
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Contact Phone
*
Contact Email
*
First Name
Last Name
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Name of Practice
Office Address
Office Hours
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
City
State
Postal code
Ranking
Please Choose 1
A
B
C
D
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(A=Most Revenue, B=Average Revenue, C=Emerging/No Growth, D=New)
Contact Notes
Years In Practice?
Career Stage
Career Stage
Early
Middle
Late in career
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Planning to add associates?
Planning to add associates?
Yes
No
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Admin Staff
Retirement Timeline
Office Manager Last Name
Office Manger First Name
Office Manager Cell Phone
Office Manager Email
Preferred Routine Contact Method
Preferred Routine Contact Method
Email
Text Message
Phone Cell
Phone Office
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Best Day of Week
Best Time of Day
Additional Admin Team Members
Hygiene Team Names
Key Insights to Deepen the Relationship
Clinical and Patient Care
Team and Practice Operations
Growth and Economics
What Does The Doctor Refer?
What Does The Doctor Refer?
Essential and Obvious Care
Some Growth Cases and Case Types
Prescription Procedures for Restorative Goals
Comprehensively and Interdisciplinary
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When Does The Doctor Refer?
When Does The Doctor Refer?
Only When In Trouble or Essential
Only Cases Supported by Insurance
Some cases driven by patient value
Cases with comprehensive value
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Doctor Refers To Our Practice When
Doctor Refers To Our Practice When
Only as a backup
Limited case types only
Shared with other specialists
We are their preferred specialist in most cases
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Who Selects The Specialist For The Patient?
Who Selects The Specialist For The Patient?
Doctor usually selects specialist
Patient is given a list to select from
Team member usually selects specialist
Other
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Patients From This Doctor Arrive
Patients From This Doctor Arrive
With limited value for care and our specialist
Arrive with comprehensive value for care and our specialist
With some value for care and our specialist
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